Laserfiche WebLink
BACKFILL EXCAVATION CERTIFICA* <br /> Project Location:e 105.0 P/ ftCAvAwyLr 7�yKyi CA, ?S-37165-, � <br /> Owner: &-Iks Phone No: / ry s� ./ <br /> Contractor: Gl-G• Me l d"Cy Phone No:� �rOF- 7 ed-112/cp License No: 71k a? /3 <br /> INDICATE METHOD OF BACKFILL QUALITY ASSURANCE <br /> 1. Submission of Soil Engineer's Compaction Report within 30 days of project completion,or <br /> 2. Submission of verification, e.g., load ticket, within 30 days of project completion that one of the following materials was <br /> placed in the excavation in 12" lifts: <br /> A. Pea gravel--smooth,rounded material not more than one-half(1/2)inch in diameter <br /> Crushed rock--self-compacting material not more than three-quarters (3/4) inch in cross sectional <br /> measurement. 44" e <br /> baGkfill- 7-4 <br /> DECLARATION <br /> I hereby certify that a Soil Engineer's Compaction Report will be submitted within 30 days ofroject completion, or submission of <br /> verification that the select material described above will be placed at a minimum of five (5 cubic yards per 1000 gallon tank <br /> displacement and that the entire excavation will be backfilled and compacted to insure compliance with the Uniform Building Code <br /> Appendix Chapter 70. <br /> ame not <br /> * ' S <br /> to t <br /> r <br /> tgnature <br /> * Shall be the responsible managing employee on the license or authorized agent. <br /> EI-123046 (Revised 10/16/03) Page 1 I <br />